From the Guidelines
A 57-hour-old infant with a bilirubin level of 9 mg/dL should return for a recheck within 24 hours to monitor for potential hyperbilirubinemia and ensure the bilirubin level is not rising too rapidly. This recommendation is based on the latest guidelines from the Pediatrics journal, which emphasize the importance of monitoring bilirubin levels in newborns to prevent severe neonatal hyperbilirubinemia 1. According to the study, total serum bilirubin (TSB) should be used as the definitive diagnostic test to guide all interventions, and the rate of rise of TSB can be used to identify possible hemolysis 1. Key factors to consider in the follow-up visit include the infant's gestational age, neurotoxicity risk factors, and age in hours, as these factors influence the phototherapy treatment thresholds 1. During the return visit, the healthcare provider will measure the bilirubin level again to ensure it's not rising too rapidly or approaching treatment thresholds, and to evaluate the underlying cause of hyperbilirubinemia if necessary 1. Some important points to consider in the management of this infant include:
- The bilirubin level is not immediately concerning, but close monitoring is important because bilirubin levels typically peak between days 3-5 of life (72-120 hours)
- Parents should continue frequent feeding (8-12 times daily) to promote bowel movements that help eliminate bilirubin
- Parents should watch for worsening jaundice (yellowing) extending to the abdomen, arms, or legs, and for concerning symptoms like poor feeding, lethargy, or high-pitched crying, which would warrant immediate medical attention
- Regular monitoring is essential because untreated severe hyperbilirubinemia can lead to kernicterus, a form of brain damage. The decision to discontinue phototherapy should be individualized, considering the TSB level at which phototherapy was initiated, the cause of the hyperbilirubinemia, and the risk of rebound hyperbilirubinemia 1. In general, infants who received phototherapy should have a follow-up TSB measure within 1 to 2 days after phototherapy discontinuation, unless it has been ≥24 hours since phototherapy was stopped, in which case it is an option to use transcutaneous bilirubin (TcB) 1.
From the Research
Assessment of Bilirubin Levels in Infants
- The bilirubin level of 9 in a 57-hour infant is a concern that requires monitoring, as high bilirubin levels can lead to hyperbilirubinemia and potentially severe complications 2.
- According to a study published in Pediatrics in 2002, a serum bilirubin level of > or =5 mg/dL and an increase in serum total bilirubin concentration of >0.5 mg/dL/h in the first 24 hours is considered significant hyperbilirubinemia 3.
- Another study published in Indian Pediatrics in 2010 found that risk factors for significant bilirubin rebound after phototherapy included birth at >35 weeks of gestation, birthweight <2000 g, and onset of jaundice at >60 h of age 4.
Recommendations for Follow-up
- The American Academy of Pediatrics recommends that infants with bilirubin levels above 15 mg/dL should be closely monitored and may require phototherapy 2.
- A study published in Advances in Neonatal Care in 2006 highlights the importance of proper nursing care during phototherapy, including ensuring effective irradiance delivery, maximizing skin exposure, and monitoring thermoregulation 5.
- Given the infant's current bilirubin level and age, it is recommended that they return for a recheck to monitor their bilirubin levels and assess the need for potential treatment, such as phototherapy 3, 4, 2.